Time for surgeons to earn their wings

Pilots never expect to hit a flock of birds on take off, or flame out an engine in mid-flight. No one plans to get disoriented in the air or have an equipment malfunction miles from the nearest airfield. And, it certainly isn’t routine to fly into hostile airspace with a heightened awareness of the known ground threats, the position of each member of your formation, and the safety of the ‘friendlies’ on the ground at stake.

As an Air Force pilot, I never planned for these emergency scenarios to occur. But, when they did, I knew exactly what to do because I was trained to quickly assess a crisis situation and respond to it with a set series of steps. Through training, the use of a checklist, and my “heads-up display” (HUD), I was able to analyze the situation, take the appropriate action, and bring my jet safely back to base, even when cards were stacked against me.

When I started medical school, fresh off a combat tour in Afghanistan, my aviation training was still foremost in my mind. And, as I completed my first surgical rotation, I couldn’t help but think, “Surgeon’s could learn a lot from fighter pilots …”

Much has been written lately about whether or not surgeons could benefit from the successful aviation safety practices used by pilots. As the developer of an aviation-based patient safety system and the CEO of a company dedicated to bringing aviation technology into the operating room, I admit that I am biased, but I am also uniquely qualified to address this discussion.

Lets start with this: The human body is not an airplane.

Even when compared to a combat situation, there are more possible points of failure in a human body than there are in an airplane. That being said, I don’t believe anyone is comparing patients to planes! As an advocate of aviation safety practices in medicine, I understand that there will be necessary modifications due to the complexity of medicine. But that doesn’t mean the application of “Crew Resource Management (CRM)” can’t be successfully adapted for the surgical suite. The ‘dashboards’ currently in production by multiple companies are a good start to enhancing communication in the Operating Room, but there is more work to be done. In an aircraft, the HUD gives the pilot all the critical information they need for a successful flight – at eye level. In the operating room, surgeons need that same technology.

Next: Surgery isn’t like flying — there is an art to it.

I have heard the criticism that there isn’t an “art” to flying and that we simply do everything “by the book.” This is a common misperception highlighting a misunderstanding of flight procedures. Just like surgeons, pilots, and particularly fighter pilots, do not like to be told how to do things. We each have our own techniques that we use to lead a formation of aircraft, accomplish a bombing strike, or engage in air-to-air combat. There are good techniques and there are bad techniques, a statement that is certainly true for both pilots and surgeons. Unlike surgeons, however, pilots are given a ‘check-ride’ each year to ensure they are meeting the minimum safety and execution standards of flight, and the grade they receive is part of their permanent record. If their techniques are ineffective, or unsafe, they are corrected and shown another way to accomplish the objective.

How are surgeon’s techniques evaluated for safety and effectiveness? How do we separate the skilled from the novice? How do we ensure that each surgeon’s “art” is both safe and effective? We need quality data to make these assessments and we need to establish a universal ‘Standard of Care’ which we measure surgeons against.

And finally: “I don’t need a checklist telling me what to do.”

This one’s my favorite. Like surgeons, fighter pilots study, train, and pursue excellence in their skill. As pilots, we don’t have a checklist that tells us every minute thing we need to do, and if we did, no one would use it! We do, however, use our checklists to ensure essential safety steps are completed, and we use them in crisis situations to focus our thoughts, keep us on track, and ultimately get us back on the ground safely. A checklist is a tool, and it is a powerful one. Studies repeatedly show that checklist use decreases preventable errors, and yet, implementation has been slow as the medical community resists the idea.

I’ve spent a great deal of time thinking about both the similarities and the differences between fighter pilots and surgeons and I maintain that surgeons and surgical outcomes could benefit from implementation of proven measures already practiced in fighter aviation.

As any good fighter pilot would, I expect to get some “debrief” items from both surgeons and pilots alike. I welcome your feedback and look forward to a lively discussion.

Time for surgeons to earn their wings 4 comments

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Jay Flottmann

I like it! Why not use proven techniques to reduce preventable error? Checklists aren’t new per se but who better than a fighter pilot and physician to develop a team to capture the idea?

Thomas D Guastavino

I completely agree. Every surgeon should support patient safety ideas like hand washing, site verification, pre-op antibiotics, and VTE prophylaxis. In fact, I, and every surgeon I knew, support it so much that we have been doing it for over 25 years. We didnt need a nurse running after us with a checklist to know the best way to handle these issues. Apparently we have decided that beauracracy trumps experience.

Jeff Woolford

Hand washing, site verification and pre-op antibiotics were once thought to be radical ideas themselves, but their benefit is now undeniable! The idea of checklists in the operating room is not a new idea, but implementation has been slow. I completely agree that a paper checklist implemented and filled out by staff members is additional red-tape that is both unwelcome and unnecessary. Our system does not include a single paper checklist and has been designed around the needs of the surgeon. The surgeon creates the checklist and then interacts with it throughout the surgery — it is a dynamic technology that responds to gestures and voice commands. At the end of the procedure you can print a log of everything that was done, saving everyone time and energy. Experience always trumps bureaucracy, in my opinion, but the power of a checklist is that it gives younger surgeons the tools to hone their craft and ensure patient safety.

Jeff Woolford

I couldn’t agree more! The debrief is a critical element to improving patient safety. The challenge with the medical debrief is the lack of data collected during a long procedure. In aviation we can ‘review tapes’ to analyze everything from routine maneuvers to the effectiveness of bombing runs. We use these tapes to augment the debrief and answer questions. Surgeons don’t currently have that ability. Our system is not only built around the needs of the surgeon, it also collects data throughout each procedure. This data is a powerful learning tool that can be used in a surgical debrief. Surgeons also have the ability to record voice and video during critical stages to further enhance learning. Checklist technology and the “debrief” go hand-in-hand and their implementation in medicine will most certainly save lives!